Tips on Evaluating, Treating Snoring

Evaluating and treating snoring in the office setting is something for which otolaryngologists are frequently called upon. Two experts offered pointers in a session at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation. The discussion was led by Scott Brietzke, MD, MPH, director of pediatric otolaryngology and sleep surgery at the Walter Reed Army Medical Center in Washington, D.C., and Peter O’Connor, MD, director of sleep surgery at the San Antonio Military Health System.*

Up to a third of healthy adults snore routinely, and the condition seems to increase with age. Drs. Brietzke and O’Connor emphasized that snoring is not just a social issue—there can be real consequences even if patients don’t have obstructive sleep apnea (OSA). “There is measurable mortality just from snoring,” Dr. Brietzke said. “It’s not a huge effect; it’s a small one, just barely into the measureable range. But it definitely exists.”

When a patient presents as a snorer, the first step should be to rule out OSA, which is linked to increased morbidity and mortality. There is a risk in treating the snoring without treating the underlying sleep apnea. “You might actually take away that warning signal,” Dr. Brietzke said.

Treating Palatal Flutter

Palatal flutter, the vibration of soft tissue in the throat, represents 80% to 85% of all socially bothersome snoring. The concept behind all of the procedures for treating this condition is to stiffen the palate by causing scar tissue to form.

All procedures used to treat palatal flutter—uvulopalatopharyngoplasty (UPPP), cautery-assisted palatal stiffening operation (CAPSO), snoreplasty, and palatal implants—offer a success rate of approximately 80%. So, rather than trying to determine which treatment works better, physicians should use other factors—such as cost, access, and uvula size—to settle on the right one.

Asking patients about the use of their voices is an important step to take before performing a procedure, Dr. O’Connor said. His sister-in-law, for instance, was an opera singer who will not allow him to perform a procedure because she worries it will change her voice acoustics. “I always ask my patients about their voice,” he said.

The Pang-Rotenburg sign, which helps to determine whether palatal flutter is happening by asking patients to make snoring sounds with their mouths closed—can be useful in predicting how well surgery is likely to work (Laryngoscope. [Published online ahead of print May 20, 2015]. doi: 10.1002/lary.25392). Both Dr. O’Connor and Dr. Brietzke also emphasized the importance of assessing the role of the uvula in snoring and correcting a problem if one exists, a concept that has gained wider acceptance in recent years. “If there’s a big beefy uvula there and you don’t do anything with it, you’re going to lose success,” Dr. Brietzke said.

Patients should be cautioned that the procedures will not work immediately, because scar tissue has to form. Also, because scar tissue softens and droops over time, relapses eventually occur in most patients.

Injection snoreplasty, in which an injection is made into the fluttering part of the palate to cause scarring, is another option, Dr. Brietzke said, but it does not address the uvula. “The uvula is usually my determining factor on which one I reach for,” he said. If the uvula doesn’t look worrisome, he probably starts there; if it does, he may move on to something such as a CAPSO, in which a midline palatal scar is induced.

Other Treatments

Oral appliances such as a mouthpiece, which can reposition the jaw or the tongue, can be effective if the problem isn’t the palate, Dr. O’Connor said. Medical

interventions such as pseudoephedrine, the anti-nausea medication domperidone—not available in the United States—and the antidepressant protriptyline have shown some benefit in studies, probably due to their neurologic effects and changes to the tone of the muscles. “There’s a variety of different reasons for why that may occur, but it’s something certainly to consider,” Dr. O’Connor said. Nothing is currently available at this point, however, and these medications need to be studied further.

Interventions such as pillows, lubricants, and stents have not been found to have significant effects across a large group of patients when studied, Dr. O’Connor added. For select patients, these products may be beneficial, but determining which ones they may assist can be difficult.

Oropharyngeal exercises, developed after it was observed that users of the didgeridoo were found not to snore, can also help with muscle tone. Dr. Brietzke said the effect is “not overwhelming” but is definitely present.

*The speakers’ comments are their private views and do not reflect the official views of the Department of the Army or the Department of Defense.

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Thomas Collins is a freelance medical writer based in Florida.